Chapter 16: Treatment of Psychological Disorders

 

BRIEF CHAPTER OUTLINE

 

Biological Treatments

            Drug therapies

                        Drug Treatments for Mood and Anxiety Disorders

                        Drug Treatments for Schizophrenia

            Psychosurgery

            Electric and Magnetic Therapies

                        Electroconvulsive Therapy

                        Repetitive Transcranial Magnetic Stimulation

Breaking New Ground: Deep Brain Stimulation for the Treatment of Severe Depression

Psychological Treatments for Psychological Disorders

            Psychodynamic Therapy

Humanistic Therapy

Behavioral Treatments

Cognitive and Cognitive-Behavioral Treatments

Group Therapies

Psychology in the Real World: Preventing Depression

Combined Approaches

            Drugs and Psychotherapy

            Integrative Therapies

            Mindfulness Training Combined with Psychotherapy

Effectiveness of Treatments

            Effectiveness of Biological Treatments

            Effectiveness of Psychological Treatments

Effectiveness of Integrative Approaches

             Combining Drugs and Psychotherapy

             Integrative Therapies

Making Connections in the Treatment of Disorders:  Approaches to the Treatment of Anxiety Disorders

Chapter Review

EXTENDED CHAPTER OUTLINE

 

  • Nowhere can one see the complex interaction between biology and environment more profoundly than in the development and treatment of psychological disorders.
  • Although treatment is often discussed in term of biologically versus psychologically based, we must be clear that both categories of treatment can and do modify the brain.

 

BIOLOGICAL TREATMENTS

  • Three major forms of treatment exist: biologically based, psychologically based, and integrative.

 

Drug Therapies

Drug Treatments for Mood and Anxiety Disorders

  • Monoamine oxidase (MAO) inhibitors: the first pharmaceuticals used to treat depression. These drugs reduce the action of the enzyme monoamine oxidase, which breaks down monoamine neurotransmitters (including norepinephrine, epinephrine, dopamine, and serotonin) in the brain. By inhibiting the action of this enzyme, MAO inhibitors allow more of these neurotransmitters to stay active in the synapse for a longer time, which presumably improves mood.
  • Unfortunately, MAO inhibitors have many serious side effects and interactions.
  • Tricyclic antidepressants: work by blocking the reuptake of both serotonin and norepinephrine almost equally. Hence, they work by making more of these neurotransmitters available in the brain. The tricyclics produce unpleasant side effects, however, such as dry mouth, weight gain, irritability, confusion, and constipation. They are still popular for treating depression and are also used for chronic pain management, ADHD, and bedwetting.
  • Selective serotonin reuptake inhibitors (SSRIs): make more serotonin available in the synapse, as depressed people have typically low levels of serotonin. SSRIs and are among the most widely prescribed psychotherapeutic drugs in the United States today.
  • CONNECTION: People with depression have deficiencies in either the amount or the utilization of serotonin in certain parts of the brain. (See Chapter 15.)
  • Serotonin, like all neurotransmitters, is released from the presynaptic neuron into the synapse. It then binds with serotonin-specific receptor sites on the postsynaptic neuron to stimulate the firing of that neuron. Normally, neurotransmitters that do not bind with the postsynaptic neuron will be either taken back up into the presynaptic neuron (a process called reuptake) or destroyed by enzymes in the synapse. The SSRIs inhibit the reuptake process, thereby allowing more serotonin to be received and used by the postsynaptic neuron.
  • By allowing more serotonin to be used, the SSRIs alleviate some of the symptoms of depression.
  • Although prescribed primarily for depression, they are also prescribed for the treatment of certain anxiety disorders, especially OCD, as well as disorders of impulse control, such as compulsive gambling.  SSRIs can incur some side effects, such as agitation, insomnia, nausea, and difficulty in achieving orgasm.
  • Bupropione: another widely used antidepressant that is chemically unrelated to the tricyclics, MAO inhibitors, and SSRIs. It inhibits the reuptake of norepinephrine and dopamine, both of which are excitatory neurotransmitters involved in arousal and positive emotion.
  • Benzodiazepines: (e.g., Valium) prescribed for anxiety, as they have calming effects. Unfortunately, they can be addictive.
  • Lithium: has long been prescribed for its ability to stabilize the mania associated with bipolar disorder. We do not know how lithium works, although it appears to influence many neurotransmitter systems in the brain, including glutamate, the major excitatory neurotransmitter in the brain, which appears to play a substantial role in schizophrenia. Taking lithium can be unpleasant and dangerous, as it can cause diarrhea, nausea, tremors, cognitive problems, kidney failure, brain damage, and even adverse cardiac effects.
  • CONNECTION: As explained in Chapter 6, drug tolerance is a general principle of drug use, which refers to how people require more and more of the drug to get the effect from it that they desire. It occurs with commonly used substances, such as caffeine, as well as prescription drugs.

Drug Treatments for Schizophrenia

  • Phenothiazines: help diminish hallucinations, confusion, agitation, and paranoia in people with schizophrenia. The major anti-schizophrenia drugs are those that reduce the availability of dopamine in the brain.
  • Traditional antipsychotics: The phenothiazines and haloperidol were the first medications used to manage psychotic symptoms. Unfortunately, they have many unpleasant side effects, including fatigue, visual impairments, and a condition called tardive dyskinesia, which consists of repetitive, involuntary movements of jaw, tongue, face, and mouth (such as grimacing and lip smacking) and body tremors.
  • Atypical antipsychotics: do not have these side effects. Many physicians now consider the atypical antipsychotics the first line of treatment for schizophrenia. These drugs preferentially block a different type of dopamine receptor than the traditional antipsychotics do, which makes them less likely to create tardive dyskinesia.
  • CONNECTION: Some disorders, such as schizophrenia, can be caused in part by genes that are expressed only under specific environmental circumstances, as discussed in Chapter 15.

 

Psychosurgery

  • Prefrontal lobotomy: severing of connections between the prefrontal lobes and the lower portion of the brain.
  • The belief was that this would disconnect the thinking and emotional areas of the brain. However, prefrontal lobotomies produced profound personality changes, often leaving the patient listless or subject to seizures; some patients were even reduced to a vegetative state.
  • After the introduction of the traditional antipsychotic medications, lobotomy fell out of favor. Today a few, highly constrained forms of brain surgery are occasionally performed, but only as a last resort after other forms of treatment have been unsuccessful.

 

Electric and Magnetic Therapies

Electroconvulsive Therapy

  • Electroconvulsive therapy (ECT): involves passing an electrical current through a person’s brain in order to induce a seizure. This started because of the observation that people who have seizures become calm after.
  • Research eventually demonstrated, however, that ECT did not treat the symptoms of schizophrenia effectively at all, and it disappeared as a viable therapy for years.
  • As just mentioned, it resurfaced later as a treatment for people with severe cases of depression.
  • Standard ECT treatment involves up to 12 sessions over the course of several weeks. Each session lasts about 20 minutes. Although some people report immediate relief of their depressive symptoms it creates some permanent memory loss and other types of cognitive damage because it actually destroys some brain tissue.

Repetitive Transcranial Magnetic Stimulation

  • Repetitive transcranial magnetic stimulation: Physicians expose particular brain structures to bursts of high-intensity magnetic fields instead of electricity. Like ECT, repetitive transcranial magnetic stimulation is usually reserved for people with severe depression who have not responded well to other forms of therapy.

Breaking New Ground: Deep Brain Stimulation for the Treatment of Severe Depression

·         See “Breaking New Ground” section for detailed explanation.

Psychological Treatments for Psychological Disorders

  • Psychotherapy: The use of psychological techniques to modify maladaptive behaviors or thought patterns, or both, and to help patients develop insight into their own behavior.  It is carried out by a therapist and a client, either alone or in groups.

 

Psychodynamic Therapy

  • Psychodynamic psychotherapy: aims to uncover unconscious motives that underlie psychological problems.
  • Free association: A Freudian technique that involves the client recounting a dream and then takes one image or idea and saying whatever comes to mind, regardless of how threatening, disgusting, or troubling it may be. After this has been done with the first image, the process is repeated until the client has made associations with all the recalled dream images. Ideally, somewhere in the chain of free associations is a connection that unlocks the key to the dream.
  • Symbols: drdrDream images are thought of as representing or being symbolic of something else.
  • Transference: Another Freudian concept, here the client reacts to a person in a present relationship as though that person were someone from the client’s past.
  • Defense mechanisms: operate unconsciously and involve defending against anxiety and threats to the ego.
  • Repression: involves forcing threatening feelings, ideas, or motives into the unconscious.
  • In psychodynamic therapy, dream interpretation and transference are used to uncover repressed defenses and unconscious wishes. 
  • Catharsis: the process of releasing intense, often unconscious, emotions in a therapeutic setting.  
  • Discussion: You may want to ask students what they think about theses concepts. It reminds them that there is little evidence for repression.

 

Humanistic Therapy

  • The most prominent figure in humanistic therapy is Carl Rogers (1951), who developed:
  • Client-centered therapy: The main idea of client-centered therapy is that people are not well because there is a gap between who they are and who they would ideally like to be.
  • Unconditional positive regard: The therapist must show genuine liking and empathy for the client, regardless of what he or she has said or done.

 

Behavioral Treatments

  • Behavior therapies: The application of classical and operant conditioning to treat psychological disorders. They focus on changing behavior.
  • CONNECTION: Many behavioral therapies rely on basic principles of classical and operant conditioning, including the powerful role of reinforcement. For a review of these basics types of learning see Chapter 8.
  • Token economies: A technique based on a simple principle: Desirable behaviors are reinforced with a token, such as a small chip or fake coin, which can then be exchanged for privileges.
  • Recent uses include treatment of substance abuse by people with schizophrenia. Each time the patients did not use drugs, they were rewarded with small amounts of money. Coupled with problem-solving and social-skills training, this token system helped control substance abuse in hospitalized patients with schizophrenia, who are generally very hard to treat.
  • Systematic desensitization: used to treat simple phobias. Systematic desensitization pairs relaxation with gradual exposure to a phobic object. The therapist helps the client learn relaxation techniques that he or she can use when experiencing anxiety.
  • Systematic desensitization involves three levels of exposure to a phobic object:
  • Imagined exposure: people simply imagine contact with the phobic object.
  • Virtual reality exposure: virtual reality software allows clients to simulate flying or other objects of fear.
  • In vivo exposure: the client makes real-life contact with phobic object.
  • Flooding: an extreme form of in vivo exposure in which the client experiences extreme exposure to the phobic object.

 

 

Cognitive and Cognitive-Behavioral Treatments

  • Cognitive therapy: Any type of psychotherapy that works to restructure irrational thought patterns.
  • Aaron T. Beck (1976) developed perhaps the best-known form of cognitive therapy. Typically, the therapist helps the client identify irrational thought patterns and then challenges these thoughts. Cognitive therapy is structured and problem-oriented, with the primary goal of fixing erroneous thought patterns. It is also time-limited and involves a collaborative effort by the therapist and the client.
  • Cognitive-behavioral therapy (CBT): Tries to change both thoughts and behavior.
  • CBT entails restructuring thoughts, loosening the client’s belief in irrational thoughts that may perpetuate the disorder, and offering incentives for acquiring more adaptive thought and behavior patterns. Cognitive-behavioral therapy is a short-term psychological treatment that has been successfully applied to disorders as varied as depression, phobias, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder, eating disorders, and substance abuse.
  • Depressogenic thinking: Thinking that tends to help generate or support depressed moods.  CBT has revolutionized the treatment of many psychological disorders.

 

Group Therapies

  • Group therapy: Several people who share a common problem all meet regularly with a therapist to help themselves and one another; the therapist acts as a facilitator. Group therapies often follow a structured process with clear treatment goals.
  • Support groups: Meetings of people who share a common situation, be it a disorder, a disease, or coping with an ill family member. They meet regularly to share experiences, usually without programmatic treatment goals. They usually have a facilitator, a regular meeting time, and an open format.
  • Groups can be categorized in terms of their focus, such as eating disorders, substance abuse, treatment of OCD, or coping with bereavement, and may be time limited or ongoing.

 

Psychology in the Real World: Preventing Depression

  • Prevention: Focuses on identifying risk factors for disorders, targeting at-risk populations, and offering training programs that decrease the likelihood of disorders occurring. Certain behaviors or coping skills may help stave off depression.
  • Van Voorhees and colleagues (2008) conducted a large-scale study of risk factors for adolescent depression. They found that several characteristics put teens at risk for a depressive episode, including being female, of a nonwhite ethnicity, of low-income status, having poor health, and experiencing parental conflict.
  • Teens who felt more connection among family members, warmth from their parents, peer acceptance, and who did better in school and participated in religious activities were less likely to have a depressive episode than others.
  • Psychosocial factors that increase the risk of depression include life stress and having a pessimistic outlook on life.
  • The Penn Resiliency Program (PRP) is designed to prevent depression and other psychological disorders through the cultivation of resilience and skills for coping with stress, problem solving, and cognitive restructuring.
  • They found that weekly 90-minute sessions over a 12-week period significantly reduced depressive symptoms at follow-up, compared to the control group and other interventions. However, 6 months later there were no differences between groups.
  • The PRP interventions trials have been set up to allow for follow-up of the same group of people for year, so we will be able to see if such skill development has a long-term protective effect on mental health.
  • Some integrative approaches combine different types of psychotherapy or combine nontraditional practices with traditional approaches.

 

COMBINED APPROACHES

 

Combining Drugs and Psychotherapy

  • Drugs can modify some of the debilitating effects of a disorder enough so that the patient can function well enough to learn techniques that might help in changing his or her problematic thinking and behavior.
  • This approach works best for mood and anxiety disorders, in which thinking is not severely impaired.

Nature-Nurture Pointer: Often, treatments that combine biological and psychotherapeutic approaches together are more effective than one approach only.

 

Integrative Therapies

  • Integrative therapy: The clinician is trained in many methods and use those that seem most appropriate given the situation; he or she is not loyal to any particular orientation or treatment.
  • Prolonged Exposure therapy: An integrative treatment program for people who have post-traumatic stress disorder. It combines CBT with methods of the imagined exposure form of systematic desensitization and relaxation.

 

Mindfulness Training Combined with Psychotherapy

  • Some recently developed therapies integrate the nontraditional practice of mindfulness meditation with psychotherapeutic techniques to treat psychological disorders. In mindfulness meditation, the mediator is trained to note thoughts as they occur, without clinging to them.
  • CONNECTION: Mindfulness meditation practices help people become aware of everything that occurs in the mind for what it is:  a thought, an emotion, or a sensation that will arise and dissipate. In Chapter 6, we discuss the effects of mindfulness training on brain physiology and experience.

·         Mindfulness-based cognitive therapy (MBCT): This approach combines elements of CBT with mindfulness meditation.

Nature-Nurture Pointer: By restructuring thoughts, MBCT is also restructuring synaptic connections involved in learning, memory, and emotion.

·         Dialectical behavior therapy (DBT): a program developed for the treatment of borderline personality disorder that integrates elements of CBT with exercises aimed at developing mindfulness without meditation.

·         The Four Steps: Self-instructional and involve a progression of cognitive and mindfulness exercises aimed at helping people with OCD to recognize intrusive thoughts as nothing but a symptom, and not a defining characteristic of the individual. The four steps are Relabel, Reattribute, Refocus, and Revalue.

 

EFFECTIVENESS OF TREATMENTS

 

Effectiveness of Biological Treatments

  • The SSRIs and tricyclics show comparable effectiveness in the treatment of depression.
  • Lithium is still widely used for treatment of mania, although the evidence for lithium’s effectiveness in treating “acute” phases of mania is weak in spite of its regular use for this purpose in the United States.
  • The treatment of schizophrenia still presents a huge problem for mental health professionals. Both traditional and atypical antipsychotic drugs work best on the positive symptoms of schizophrenia, such as hallucinations and delusions, but are generally less effective on the negative symptoms, such as flattened affect and the cognitive confusion that is characteristic of the disorder.
  • However, one of the major problems in treating schizophrenia is persuading patients to continue taking the medication. Because of the unpleasant and often dangerous side effects of these drugs, patients often stop taking them. Up to 74% of people using traditional and atypical antipsychotics discontinue treatment.
  • ECT is regarded as a treatment of last resort for severely depressed people who have not responded to any other therapy. A recent controlled trial found that ECT and pharmacological therapy for depression were about equally effective in preventing relapse in people with major depressive disorder, but each form of treatment helped only about half of the people studied.

 

Effectiveness of Psychological Treatments

  • Evidence-based therapies: Treatment choices based on the empirical evidence of their efficacy.
  • Years ago, a review of the literature on the effectiveness of various types of psychotherapies showed that people who received any kind of therapy were better off on a number of outcomes relevant to mental status than most people who did not receive therapy.
  • The study revealed no differences between behavioral therapies and psychodynamic ones. This meta-analysis, however, was conducted before the advent of cognitive-behavioral therapy.
  • In general, then, the usefulness of psychotherapy depends on the nature of the disorder being treated and the state of the patient’s mental health.
  • Cognitive therapy (CT) and cognitive-behavioral therapy have shown perhaps the greatest effectiveness of any form of psychotherapy for treating various psychological disorders, but it is especially effective for certain cases of depression and anxiety disorders.
  • Recent data suggest that cognitive therapy is at least as effective as antidepressants in treating severe depression, and in the treatment of obsessive-compulsive disorder, CBT produces decreased metabolism in the caudate nucleus, a brain area that is overactive in people suffering from this disorder.

Nature-Nurture Pointer: Psychotherapy changes the brain.

  • Behavioral treatments such as systematic desensitization are very effective for treatment of certain anxiety disorders, especially simple phobias, including performance anxiety and public speaking.

 

Effectiveness of Integrative Approaches

  • However, a major 14-month study of mental health in more than 500 children examined the relative effectiveness of medication, behavioral treatment, and the combination of the two approaches in treating a variety of disorders. For AD/HD, for example, the combination of drugs and behavioral therapy was superior to behavioral intervention and better than medication alone for most outcome measures.
  • Clinical research shows that prolonged exposure therapy (an integrative CBT approach) is effective at substantially reducing symptoms of PTSD.

·         Borderline personality disorder has long been considered nearly untreatable, but DBT is quite effective in reducing the symptoms of this disorder: reducing self-inflicted harmful behaviors, lowering scores on depression questionnaires, decreasing dysfunctional patterns associated with substance abuse, and increasing the likelihood of staying in treatment.

·         The last combined mindfulness technique is the Four Steps. It may take several months to progress through the Four Steps. But the treatment appears to work. In fact, Four Steps training not only helps break the thinking-behavioral cycles of OCD, but also (or for this reason) changes the brain circuitry that appears to support repetitive thinking and behavior.

Nature-Nurture Pointer: Combined psychotherapy and mindfulness training can rewire brain circuitry in people with OCD.

·         CONNECTION: PET is a form of brain imaging, older than fMRI, which measures metabolism in the brain. See how it compares with other imaging techniques in Chapter 3.

 

Making Connections in the Treatment of Disorders: Approaches to the Treatment of Anxiety Disorders

  • See “Making the Connections” section for detailed explanation.

 

KEY TERMS

 

atypical antipsychotics: newer antipsychotic drugs, which do not create tardive dyskinesia. Examples include Clozapine (Clozaril), olanzapine (Zyprexa), and risperidone (Risperdal).

barbiturates: another class of drug for anxiety; has sedative, calming effects. These drugs can be addictive and carry risk of overdose.

behavior therapies: therapies that apply the principles of classical and operant conditioning to treat psychological disorders.

benzodiazepines: (Valium, Librium) a class of drugs prescribed for anxiety; has calming effects and can be addictive, but less dangerous than the barbiturates.

bupropione: (trade name Wellbutrin) another widely used antidepressant that is chemically unrelated to the tricyclics, MAO inhibitors, and SSRIs. It inhibits the reuptake of norepinephrine and dopamine.

catharsis: the process of releasing intense, often unconscious, emotions in a therapeutic setting.   

client-centered therapy: a form of humanistic therapy developed by Carl Rogers, in which the therapist must show genuine liking and empathy for the client, regardless of what he or she has said or done.

cognitive therapy: any type of psychotherapy that works to restructure irrational thought patterns.

cognitive-behavioral therapy: an approach that combines techniques for restructuring irrational thoughts with operant and classical conditioning techniques to shape desirable behaviors.

defense mechanisms: processes that operate unconsciously and involve defending against anxiety and threats to the ego.

dialectical behavior therapy (DBT): a program developed for the treatment of borderline personality disorder, which integrates elements of CBT with exercises aimed at developing mindfulness without meditation.

electroconvulsive therapy (ECT): involves passing an electrical current through a person’s brain in order to induce a seizure; currently in limited use for treatment of severe depression.

flooding: an extreme form of in vivo exposure in which the client experiences extreme exposure to the phobic object.

free association: a psychotherapeutic technique in which the client recounts a dream and then takes one image or idea and says whatever comes to mind, regardless of how threatening, disgusting, or troubling it may be. This process is repeated until the client has made associations with all the recalled dream images.

group therapy: therapeutic settings in which several people who share a common problem all meet regularly with a therapist to help themselves and one another; the therapist acts as a facilitator.

integrative therapy: also called “eclectic,” this is approach to treatment in which the therapist is not loyal to any particular orientation or treatment, but rather draws on use those that seem most appropriate given the situation.

lithium: a salt that is prescribed for its ability to stabilize the mania associated with bipolar disorder.

mindfulness-based cognitive therapy (MBCT): an approach that combines elements of CBT with mindfulness meditation to help people with depression learn to not cling to negative thought patterns.

monoamine oxidase (MAO) inhibitors: one of the first class of pharmaceuticals used to treat depression; these reduce the action of the enzyme monoamine oxidase, which breaks down monoamine neurotransmitters (including norepinephrine, epinephrine, dopamine, and serotonin) in the brain.

phenothiazines: the first class of drugs used to treat schizophrenia; helps diminish hallucinations, confusion, agitation, and paranoia; creates adverse side effects, including tardive dyskinesia.

prefrontal lobotomy: a form of psychosurgery, in which the connections between the prefrontal lobes and the lower portion of the brain are severed.

psychodynamic psychotherapy: therapy aimed at uncovering unconscious motives that underlie psychological problems.

psychotherapy: the use of psychological techniques to modify maladaptive behaviors or thought patterns, or both, and to help patients develop insight into their own behavior.

repetitive transcranial magnetic stimulation: physicians expose particular brain structures to bursts of high-intensity magnetic fields instead of electricity; usually reserved for people with severe depression.

repression: a defense mechanism, which involves forcing threatening feelings, ideas, or motives into the unconscious.

selective serotonin reuptake inhibitors (SSRIs): drugs that make more serotonin available in the synapse. Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), and Celexa (citalopram) are a few of the more widely used SSRIs. Used primarily for depression and some anxiety disorders.

support groups: meetings of people who share a common situation, be it a disorder, a disease, or coping with an ill family member. They meet regularly with each other to share experiences; these groups usually have a facilitator and an open format.

systematic desensitization: a behavioral therapy technique, often used for phobias, in which the therapist pairs relaxation with gradual exposure to a phobic object, generating a hierarchy of increasing contact with the feared object, ranging from mild to extreme.

tardive dyskinesia: a side effect from the extended use of traditional antipsychotics; consists of repetitive, involuntary movements of jaw, tongue, face, and mouth (such as grimacing and lip-smacking) and body tremors.

token economies: a behavioral technique in which desirable behaviors are reinforced with a token, such as a small chip or fake coin, which can then be exchanged for privileges.

traditional antipsychotics: historically, these were the first medications used to manage psychotic symptoms.

transference: occurs in psychotherapy when the client reacts to a person in a present relationship as though that person were someone from the client’s past.

Tricyclic antidepressants: drugs used for treating depression. Examples include imipramine and amitriptyline, marketed under the trade names Elavil and Anafranil. They are also used in chronic pain management, to treat ADHD, and also as a treatment for bedwetting.

 

MAKING THE CONNECTIONS

 

Drug Treatments for Mood and Anxiety Disorders

CONNECTION: People with depression have deficiencies in either the amount or the utilization of serotonin in certain parts of the brain. (See Chapter 15.)

  • Discussion: Remind students that this is why the SSRIs are the post popular class of drugs for treating this disorder. Although researchers know how the drugs work, they are unsure as to why they work.

CONNECTION: As explained in Chapter 6, drug tolerance is a general principle of drug use, which refers to how people require more and more of the drug to get the effect from it that they desire. It occurs with commonly used substances, such as caffeine, as well as prescription drugs.

  • Discussion: This may contribute to folks with mental health issues not wanting to take their medications. Not only do most people never want to have to take a pill everyday, but the side effects and the constant readjustment can wear on patients. Ask students what they think could be effective ways to get patients to take their medications.

 

Drug Treatments for Schizophrenia

CONNECTION: Some disorders, such as schizophrenia, can be caused in part by genes that are expressed only under specific environmental circumstances, as discussed in Chapter 15.

  • Discussion: Remind students of the diathesis-stress model discussed in Chapter 15. The diathesis or gene needs to be there and then stressors or experiences in the environment “select” the disorder.

 

Behavioral Treatments

CONNECTION: Many behavioral therapies rely on the basic principles of classical and operant condition, including the powerful role of reinforcement. For a review of these basics types of learning, see Chapter 8.

  • Discussion: You may want to point out to students examples you provided back in Chapter 8 of the Shi Tzu dog bite and how that could lead to a fear. Also remind them of how little Peter was “backward conditioned” by pairing the CS with a new favorable stimulus. This is an effective behavioral strategy.

 

Mindfulness Training Combined with Psychotherapy

CONNECTION: Mindfulness meditation practices help people become aware of everything that occurs in the mind for what it is:  a thought, an emotion, or a sensation that will arise and dissipate. In Chapter 6, we discuss the effects of mindfulness training on brain physiology and experience.

 

 

 

Effectiveness of Integrative Approaches

CONNECTION: PET is a form of brain imaging, older than fMRI, which measures metabolism in the brain. See how it compares with other imaging techniques in Chapter 3.

 

Making Connections in the Treatment of Disorders: Approaches to the Treatment of Anxiety Disorders

  • The anxiety disorders are a diverse group of conditions, and thus, mental health practitioners employ a wide variety of treatment strategies to help people with these disorders.

Drug Therapies

  • There are two main categories of drug therapies.

Antidepressants 

  • Many doctors prescribe SSRIs for the treatment of anxiety disorders, especially for OCD, social phobia, post-traumatic stress disorder (PTSD), and panic disorder. People who take SSRIs for anxiety disorders report that these medications help them avoid getting caught up in certain thoughts that otherwise would snowball into anxiety.

Anti-Anxiety Medications

  • Beta-blockers: Drugs that block the action of neurotransmitters, such as norepinephrine, to quickly calm the aroused sympathetic nervous system. These medications calm the physiological symptoms of anxiety, by bringing down heart rate, blood pressure, and rate of breathing.
  • The benzodiazepines (for example, Valium) also calm the physiological arousal caused by anxiety and are widely prescribed for social phobias, panic disorder, and generalized anxiety disorder.

Psychotherapeutic Treatments

  • As we have seen, cognitive-behavioral therapy helps people with anxiety disorder identify irrational thoughts and undo thinking patterns that support fear; it also helps them modify their responses to anxiety-provoking situations.
  • Systematic desensitization is effective for the treatment of specific phobias. This process couples relaxation training with gradual exposure to the feared object and is very effective for the treatment of specific phobias, such as fears of animals, flying, and heights.
  • As we have seen, sometimes medication can help people get “over the hump” of crippling symptoms so that a nondrug therapy has a chance to work.

Integrative Therapies and Anxiety

  • There is evidence that integrative psychotherapeutic approaches offer potential relief from a range of anxiety disorders. As already noted, OCD may be treated with mindfulness meditation practices and cognitive therapy. And dialectical behavior therapy (DBT), which was developed to treat borderline personality disorder, has been used effectively to treat post-traumatic stress disorder.

 

NATURE-NURTURE POINTERS

 

Combining Drugs and Psychotherapy

Nature-Nurture Pointer: Often, treatments that combine biological and psychotherapeutic approaches together are more effective than one approach only.

  • Discussion: Remind students that many disorders are the result of nature and nurture, so combining treatments to address the two fronts makes sense theoretically. This ties in nicely with the diathesis-stress model.

 

Mindfulness Training Combined with Psychotherapy

Nature-Nurture Pointer: By restructuring thoughts, MBCT is also restructuring synaptic connections involved in learning, memory, and emotion.

·         Discussion: See the site from the MBCT organization: http://www.mbct.com/. Remind students this therapy has been shown to be effective in treating a variety of problems, not just mental health issues.

 

Effectiveness of Psychological Treatments

Nature-Nurture Pointer: Psychotherapy changes the brain.

 

Effectiveness of Integrative Approaches

Nature-Nurture Pointer: Combined psychotherapy and mindfulness training can rewire brain circuitry in people with OCD.

·         Discussion: See an article from AACAP on how early intervention appears to alter brain activity in children: http://www.medpagetoday.com/MeetingCoverage/AACAP/tb/4407.

 

Breaking New Ground: Deep Brain Stimulation for the Treatment of Severe Depression

  • Neurologist Helen Mayberg discovered what appears to be a neural switch that activates depression. In the process, she came upon a strikingly effective treatment for the disorder. The path led Mayberg to discover how a brain region called Brodmann’s Area 25 may control depression.

Prevailing Thinking About Brain Circuitry in Depression

  • Researchers and therapists therefore believed that deficiencies in neurotransmitters like serotonin and dopamine were most important for understanding depression.

Mayberg’s Breakthrough Research

  • Using PET imaging of brain activation, she and her colleagues found that patients with Parkinson’s that were depressed had reduced activity in both frontal cortex thinking areas and limbic emotional areas.
  • They also found that Area 25 was hyperactive in these patients.
  • She found this same pattern of overactivation in Area 25 in depressed people with Alzheimer’s, epilepsy, and Huntington’s disease.
  • Mayberg found depressed activity in frontal cortex areas, which fit with current models of depression, along with overactivity in Area 25.
  • Area 25 is located in the cingulate region of the prefrontal cortex, and it is surrounded by the limbic system. As such, it has connections with emotional and memory centers of the brain.
  • Mayberg reasoned that if Area 25 plays a key role in sustaining depressive thinking, one should see a reduction in activity in this area after successful treatment for the disorder.
  • She and colleagues performed PET scans of depressed people before and after a 15-20-week course of cognitive-behavioral therapy, an effective psychological treatment for depression. They did similar scans on people with depression taking an SSRI. Both groups of patients showed reduced activity in Area 25 that corresponded with clinical improvement of depressive symptoms.
  • Mayberg and her colleagues amassed evidence that an overactive Area 25 is a general feature of depression. Moreover, successful treatment by an SSRI or cognitive-behavioral therapy reduced Area 25 activation.
  • An overactive Area 25 may enable the type of negative thinking that feeds depressive states. Mayberg reasoned that if it were possible to close this gate, depression might cease. But how?
  • Deep brain stimulation: They implanted electrodes in Area 25 and delivered voltage to that area from an external stimulator. For 11 of the patients, the depression ceased almost immediately. Shortly after activation of the electrodes, these patients said that they felt “sudden calmness or lightness,” “disappearance of the void,” or “connectedness.”
  • The treatment involves brain stimulation in the operating room as well as a method for stimulating the implants in daily life. Patients wear an external pacemaker that controls the delivery of electrical stimulation to Area 25.
  • A large-scale clinical trial is under way in which Mayberg and her colleagues are studying the effects of stimulation of Area 25 on a much larger group of people with treatment-resistant depression.

Nature-Nurture Pointer: Electrical stimulation of certain areas of the brain changes mood.

  • Discussion: You may want to point out that this is not necessarily a causal relationship. That is, remind students of the nature of correlational data and how it never implies causality.

A Path to Scientific Discovery

  • Consistent findings in research with a variety of populations helped show that an overactive Area 25 is an indicator of depression.

 

INNOVATIVE INSTRUCTION

 

Additional Discussion Topics

1.   ECT: You may want to discuss with students ECT. Perhaps show a brief clip of it from   One Flew Over the Cuckoo’s Nest and ask students what they think about it still being       used today. The current utility of this treatment is extreme, so remind students that this is        reserved for the most intensive cases as a last resort.

2.   Talk Therapies: Students often get confused on the differences here. Remind students    that the difference in most approaches stems from theoretical beliefs (e.g.,   psychodynamic stems from a belief of internal conflicts that are unconscious, behavioral   from learning, etc.). This will directly correspond to the type of therapy and the methods    used. What types of therapies have students seen in movies or TV? Is one form      represented to a greater extent than others? What would it mean in terms of most           insurance policies that only pay for 10-15 visits a year?

3.   Psychopharmaceuticals: Ask students what they think about the now widespread use of psychopharmaceuticals. Maybe begin the discussion with, “How many of you know someone taking an antidepressant or anti-anxiety medication?”  This should allow a segue into a discussion on if this is because it is needed or perhaps trendy?  That is, if movie stars are found with benzodiazapans and antidepressives, what message does that send to impressionable youth?

4.   Medication: Remind students of the controversy in medicating children for disorders like ADHD. You may want to show Frontline: The Medicated Child (http://www.pbs.org/wgbh/pages/frontline/medicatedchild/) to get the discussion going. Ask them if they think children should receive medication for a disorder. You may want to remind them that unlike cholesterol, blood sugars, or HIV, the disorders commonly found in children (like ADHD) cannot be tested for in a clear manner. This is where the controversy lies.  Further, how does this carry over to adults?

5.   Behaviorism: You may want to inform students that the reason behavioral and cognitive behavioral therapies are so popular now is: 1) Their efficacy; 2) They are relatively short    in duration; and thus, 3) They are less expensive.  Ask students to generate examples of     how a disorder could be learned and then how the behavioral perspective not only    explains the disorder but also how it could be “fixed” therapeutically.

6.   Defense Mechanisms:  This is a great time to talk to students about the defense mechanisms and Freud’s concepts of dream analysis. Ask students about the few mechanisms described in the text – what do they think about them? Show this clip on dream analysis (http://highered.mcgraw-hill.com/sites/0073382760/student_view0/videos.html ) and ask students if they feel there is efficacy here.

 

Activities

1.      Assign students to take a quick quiz at allydog to test their knowledge:       http://www.alleydog.com/quizzes/abnormalquiz.asp

2.      Go to http://www.deltabravo.net/custody/rorschach.php and print one or more of the        Rorschach inkblots for use in class. Ask students to write down what they think they see.   Then ask for a few students to volunteer their answers. What they think about this            methodology? Could it be used diagnostically? You may want to end with a brief            discussion on how this measure lacks both reliability and validity.

3.      Have students go to       http://consensus.nih.gov/1998/1998AttentionDeficitHyperactivityDisorder110html.htm    and read the article on Diagnosis and Treatment of Attention Deficit Hyperactivity    Disorder from NIH. This is a 10-year-old article on ADHD. Have students then find one new source from the last 10 years and write one paragraph summarizing the initial article    and a second on the current article. Then have them write a third paragraph on where the       field should go from here.

4.      Based on all the material we have covered in this text on abuse and epigenisis and             disorders, have students try to integrate it all. Have them start at       http://www.health.am/ab/more/psychological_therapy_can_help_maltreated_children/ for an article on abused kids and therapy. Have them write a short paper synthesizing    material from the text discussing abuse and neglect, and how it affects the brain and leads         to a greater risk of mental health issues. 

 

Suggested Films

1.   One Flew Over the Cuckoo’s Nest. A classic depiction of a mental health center.

2.   A brief audio clip of Freud in 1938: http://www.youtube.com/watch?v=_sm5YFnEPBE.

3.   Introduction to psychoanalysis: http://www.youtube.com/watch?v=iX8F8sW4hCg.

4.   Frontline: The Medicated Child:         http://www.pbs.org/wgbh/pages/frontline/medicatedchild/.

5.   Dr. Sherwin Nuland discussing electroshock therapy:       http://www.ted.com/index.php/talks/sherwin_nuland_on_electroshock_therapy.html.

6.   Martin Seligman on positive psychology:       http://www.ted.com/index.php/talks/martin_seligman_on_the_state_of_psychology.html.

7.   Harvard psychologist Dan Gilbert on happiness:       http://www.ted.com/index.php/talks/dan_gilbert_asks_why_are_we_happy.html

8.   Medications and schizophrenia:          http://www.youtube.com/watch?v=pyGpa0b9n0Q&feature=user

9.   Through the Discovery channel in McGraw-Hill’s library, there are several videos you       may want to use: Bipolar, an interview with John Nash, Depression, and Phobias:            http://highered.mcgraw-hill.com/sites/0073382760/student_view0/videos.html

 

Suggested Websites

1.   Article on mediation and brain change: http://www.washingtonpost.com/wp-dyn/articles/A43006-2005Jan2.html 

2.   fMRI studies on monks: http://www.urbandharma.org/udharma8/monkstudy.html

3.   A quick quiz from the University of Washington on if MBCT would work for you:       http://depts.washington.edu/hhpccweb/article-detail.php?ArticleID=409&ClinicID=6

4.   A great site on most of the disorders: http://www.brainphysics.com/

5.   The association for behavioral and cognitive therapists: http://www.abct.org/

6.   Anxiety Disorders Association website: http://www.adaa.org/

7.   A great biological site on anxiety disorder:       http://www.brainexplorer.org/brain_disorders/Focus_Panic_disorder.shtml

8.   Department of Health’s site on alternative therapies:       http://mentalhealth.samhsa.gov/publications/allpubs/KEN98-0044/default.asp

9.   NIMH on childhood disorders: http://www.nimh.nih.gov/health/publications/treatment-of-children-with-mental-disorders/summary.shtml

10.  A great website for therapies:            http://www.psychwww.com/resource/bytopic/therapies.html

11.  A nice overview of therapies: http://web.mst.edu/~pfyc212b/Therapy.htm

 

Suggested Readings

Acton, G. S. (1998). Classification of psychopathology: The nature of language. The Journal of Mind and Behavior, 19, 243-256.

Bauer, M.S. & Mitchner, L. (2004). What is a “mood stabilizer”? An evidence-based response. American Journal of Psychiatry, 161, 3-18.

Beck, A.T., Rush, A.J., & Shaw, B.F. (1979). Cognitive Therapy of Depression. New York: Guilford Press.

Bond, G., Drake, R.E., Becker, & Mueser, K. (1999). Effectiveness of Psychiatric Rehabilitation Approaches for Employment of People with Severe Mental Illness. Journal of Disability Policy Studies 10:18–52.

Comer, R.J. (2007). Abnormal Psychology  (6th edition). New York: Worth.

Dickerson, F.B. (2000). Cognitive Behavioral Psychotherapy for Schizophrenia: A Review of Recent Empirical Studies. Schizophrenia Research 43:71–90.

Frank, E., Kupfer, D.J., Perel, J.M., Cornes, C., Jarrett, D.B., Mallinger, A.G., Thase, M.E., McEachran, A.B., & Grochoconski, V.J. (1990). Three-Year Outcomes for Maintenance Therapies in Recurrent Depression. Archives of General Psychiatry 47:1093–9.

Freud, S. (1910). The origin and development of psychoanalysis. American Journal of Psychology, 21, 181-218.

Hoagwood, K., Jensen, P.S., Petti, T., & Burns, B.J. (1996). Outcomes of Mental Health Care for Children and Adolescents, I. A Comprehensive Conceptual Model. Journal of the American Academy of Child and Adolescent Psychiatry 35:1055–63.

Lipsey, M. W. & Wilson, D. B. (1993). The efficacy of psychological, educational, and behavioral treatment. American Psychologist, 48, 1181-1209.

Shaffer, D., Fisher, P., Dulcan, M.K., Davies, M., Piacentini, J., Schwab-Stone, M.E., Lahey, B.B., Bourdon, K., Jensen, P.S., Bird, H.R., Canino, G., Regier, D.A. (1996). The NIMH diagnostic interview schedule for children, version 2.3 (DISC 2.3): description, acceptability, prevalence, rates, and performance in the MECA study. Journal of the Academy of Child and Adolescent Psychiatry, 35(7): 865-77.

Von Korff, M., Katon, W., Bush, T., Lin, E.H., Simon, G.E., Saunders, K., Ludman, E., Walker, E., & Unutzer, J. (1998). Treatment Costs, Cost Offset, and Cost-Effectiveness of Collaborative Management of Depression. Psychosomatic Medicine 60:143–9.